Credit Card Authorization Form - DOC 11 by PUHLP0J7

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									20895 Currier Road. Unit B
Walnut, CA 91789
TEL: (909) 598-0738
www.kroousa.com FAX: (909) 598-0733
FAX BACK TO Accounting Dept 909-598-0733 Confidential
CREDIT CARD PHONE PURCHASE AUTHORIZATION FORM
This form allows Kroousa, Inc to CHARGE purchases of kroousa.com products to the credit card
number entered on this form. This form must be completed in full, signed by the authorized card
holder and fax back to keep on file to be used for all charged transactions. Card Holder will take
full responsibilities for ALL transaction on this card until Written Notification is mail to
Kroousa.com
CUSTOMER ID: ________________________ SALES REP: ____________________________
COMPANY NAME: _____________________________________________________________
I, __________________________________ (Card Holder’s Full Name), HEREBY AUTHORIZED,
KROOUSA, INC. TO CHARGE PRODUCTS PURCHASE TO THE CREDIT CARD NUMBER
ENTERE, AND TO BE SHIPPIED TO ADRESS STATED BELOW.
VISA/MASTERCARD NUMBER: ___________________________________________________
EXPIRATION DATE: ___________________________ CID #: __________________________
CARDHOLDER’S SIGNATURE: ___________________________________________________
CARDHOLDER’S NAME (PLEASE PRINT): _____________________________________________
CARDHOLDER’S ADDRESS: _____________________________________________________
ZIP CODE: ________________ (BILLING MUST MATCH THE BANK STATEMENTS)
TYPE OF CARD: PERSONAL COMPANY
NATUER OF USE: UNTIL EXPIRED SINGLE PURCHASE AMOUNT: $___________________
REPLACE: OLD CARD #____________________________ (last 4 digital only)
TO BE SHIPPED TO : SAME AS ABOVE #_____________LOCATIONS
1. COMPANY NAME:_____________________________________________TEL#:_______________________
ADDRESS: ___________________________________________________________ZIP: ________________________
2. COMPANY NAME: _____________________________________________TEL#:_______________________
ADDRESS: ___________________________________________________________ZIP: ________________________
3. COMPANY NAME: _____________________________________________TEL#:_______________________
ADDRESS: ___________________________________________________________ ZIP: ________________________
4. COMPANY NAME: _____________________________________________TEL#:_______________________
ADDRESS: ___________________________________________________________ ZIP: ________________________
5. COMPANY NAME: _____________________________________________TEL#:_______________________
ADDRESS: ___________________________________________________________ ZIP: ________________________

								
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